Provider Demographics
NPI:1235293804
Name:MACKIN, LEE RICHERSON (PA-C)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:RICHERSON
Last Name:MACKIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13100 N WESTERN AVE STE 303
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-1432
Mailing Address - Country:US
Mailing Address - Phone:800-781-1220
Mailing Address - Fax:888-678-8616
Practice Address - Street 1:13100 N WESTERN AVE STE 303
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-1432
Practice Address - Country:US
Practice Address - Phone:800-781-1220
Practice Address - Fax:888-678-8616
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-508363AS0400X
OK5062363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051558619Medicare PIN
FLU6218YMedicare PIN
ALQ55388Medicare UPIN